barbara-smaller-it-s-fine-to-discover-cures-but-remember-chronic-conditions-are-our-br-new-yorker-cartoon (1)Forever there has been a power struggle between the medical school faculty and physicians in the community. For those of you who are versed in House of God, the book about medical care in the early 1970s, attendings and residents at the House as well as the students who went to BMS (Best Medical School) would reference care delivered by LMDs. This term referred to “Local Medical Doctors,” known uniformly for taking crappy care of patients who were then transferred to the “House”  where life-saving intervention would occur. The protagonist soon realized that there was more to medical care then doing stuff to people, culminating in realizing the truth in Fat Man’s Rule 13 (THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE). In the 1970s, the reality is that physicians on medical school faculty tended to earn less, a LOT less, that the LMDs, may have adding to the tension.

Somewhere about 20 years ago, LMDs traded their label for another that was even more pejorative – PCP. The Primary Care Provider concept was created in part to reduce the confusion around training requirements of physicians (Family Medicine, Internal Medicine, Pediatrics) and non-physicians (Physicians Assistant, Advanced Practice Nurse) who might provide primary care to a given patient. Patients don’t use the term, PCPs find the term demeaning, and the term doesn’t really reflect the complexity of care delivery that happens in the primary care office. Teaching hospitals, though, became Academic Health Centers and were distinguished in part by their lack of PCPs as well as their lack of desire to train them. The Academic Health Center was home to Specialists.

It is now almost 40 years since House of God was published. Obamacare is the law of the land and  the law encourages the use of primary care. This is in part because the work of Barbara Starfield demonstrated that health care is just better when people have access to primary care, and in part because a lot of work was done to demonstrate that specific models which incorporate primary care lead to better health outcomes. Programs like the Massachusetts Blue Cross Alternative Quality Contract and truly integrated systems like Kaiser and Health Partners  led to better outcomes. The work on Patient Centered Medical Home initiatives led to this specific type of primary care being incorporated in the law as well. Good primary care, so the saying goes, will keep you healthy. If you happen to get sick, it will help keep your costs down by keeping you out of the hospital. If you happen to go to the hospital, it’ll keep you from being harmed and help maintain quality care.

This week, the Houses of God are fighting back against the LMDs. The University Healthsystem Consortium (the trade organization for Academic Health Centers) put out a video entitled Through the looking glass: a new perspective on population management. Their video tells us the following in convenient cartoon form: 1) Most people just randomly become ill so don’t need a specific LMDs but instead need access to a CVS with a nameless Pee Cee Peee (their pronunciation) sitting and waiting for you to show up (and perhaps willing to give you a Z-pak “to prevent pneumonia”).  Oh, yeah, and prevention is too expensive so let’s blow off trying to get people Pap smears and mammograms and focus on treatment. 2) If you are chronically ill or sick with a serious illness, you don’t need a Pee Cee Pee at all but a House of God led team of folks. According to the video, they are sitting on the steps of the House just waiting for you to show up. 3) If you suffer from an early chronic illness you might want a Pee Cee Pee, but only get one who has the number to a specialty hotline, just in case you need one of the specialists at the House. You know how those Pee Cee Pees are.

The UHC’s vision is a dystopian one where patients are taking ambulances to the Academic Health Center for their not-well-controlled diabetes because the local House of God is 2 hours away and the Pee Cee Pee is unqualified to administer insulin. The evidence they cite for the effectiveness of this model is dated and incorrect. I can only hope that the Academic Medical Centers and their research arm, UHC Research Institute (TM), have a better plan for survival before the next “House of God” is written without them.

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